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This article provides a step-by-step approach to consenting patients for a blood transfusion in an OSCE setting. For more information on prescribing and administering blood products, see the Geeky Medics guide to administering a blood transfusion.
All patients receiving a blood transfusion need to give fully informed consent.1,2 This can be given verbally but needs to be documented in their notes.
Obtaining consent for any procedure involves discussing the benefits, possible risks and any available alternatives. Information provided should be tailored to the specific patient and the clinical situation.
All organisations which provide blood transfusions should have a local policy or guideline that provides more detail about the transfusion process, so please refer to these in practice.
Opening the consultation
Wash your hands and don PPE if appropriate.
Introduce yourself, including your name and role.
Confirm the patient’s identity by asking them to give their name and date of birth.
Explain the purpose of the conversation: “Today I’d like to talk to you about having a blood transfusion that has been recommended for you, would this be ok?”
Establish rapport and an open line of communication: “Feel free to interrupt me if you have any questions at any point”.
Make sure to check the patient’s understanding at regular intervals throughout the consultation and provide opportunities to ask questions (this is often referred to as ‘chunking and checking’).
Ideas, concerns and expectations
Ascertain what the patient already knows about the blood transfusion process. This could be their first transfusion, or they may have had many before. This will help you provide the patient with information specific to their level. You should also use this time to check their understanding and if they have any concerns. Some patients might be worried about asking questions, so reassure them that they can ask as many questions as they need.
Ideas
- “Do you know why we have suggested that you have a blood transfusion?”
- “Have you or has anyone you know had a blood transfusion before?”
- “Do you know what having a blood transfusion involves?”
Concerns
- “Is there anything that worries you about having a blood transfusion?”
- “Is there anything that you don’t understand about the process of transfusing blood?”
Expectations
- “How do you hope that receiving a blood transfusion will help you?”
- “Do you have any particular questions you want me to cover?”
What are the benefits of blood transfusion?
Potential benefits of blood transfusion include:
- Receiving a blood transfusion can relieve symptoms caused by anaemia
- It can prevent damage caused to organs associated with anaemia
- It can allow earlier mobilisation and quicker recovery after an operation, acute illness or injury
What are the possible risks of blood transfusion?
Blood transfusions in the UK are usually very safe. Donated blood is obtained, tested, handled, and stored very carefully.
However, there is a small chance that some patients may face some complications. The chances of these events happening varies, but the overall risk of a serious problem occurring is less than 1 in 10,000.3
Some of the risks of receiving a blood transfusion include:
- Identification error, whereby the patient is wrongly identified and receives the wrong blood type as a result. This could cause a severe reaction (this is classified as a never-event).
- Reactions during the transfusion such as fever, chills or a rash
- Build-up of fluid in the circulation, causing breathlessness
- Infection, such as bacteria or viruses like hepatitis B or C or HIV. Because of effective screening, the risk of this is very low (less than 1 in a million).4
- Formation of antibodies, which might make it harder to match blood if patients need another transfusion in the future.
- Iron overload can occur in long-term transfusion programmes.
For women of childbearing potential, it is essential to mention that antibodies could cause complications with a future pregnancy, possibly making their baby anaemic.
Once a patient has received a blood transfusion, they are no longer able to donate blood (mention this if relevant).
When explaining the risks to patients, it is useful to remind them that they will be checked regularly while receiving the blood and that they should tell a member of staff if they feel unwell, feel uncomfortable or have any concerns.
Example
“Blood transfusion is very safe, but as is the case with any medical procedure, there are some risks.”
“Donated blood is carefully tested and processed, so the risk of infection due to bacteria or viruses like hepatitis or HIV is tiny – less than 1 in a million. We have to check carefully that we match the right blood for you, so you need to wear an ID band and you will be asked to state your name and date of birth before starting. Occasionally, people develop a reaction during the transfusion, such as a temperature or a rash. Rarely, these can be serious. There is a small risk that fluid could build up in your circulation, making you feel short of breath.”
“Events such as these are unlikely and we will check you regularly during the transfusion. It is very important to tell a member of staff if you feel unwell at any point, so we can deal with any problems quickly. Sometimes, after one transfusion your immune system can make antibodies against the donor blood cells. These won’t affect you, but they can make it harder for us to find blood that is a match for you if you needed another transfusion.”
What are the potential alternatives?
Potential alternatives to blood transfusion may include:
- Iron replacement therapy: by tablet or intravenous infusion
- Cell salvage: also known as autologous blood transfusion. This can be performed in surgery and is a process in which the blood lost during or just after the operation is collected, filtered and given back to the patient.5
- Erythropoietin injections: the hormone that stimulates the body to make its own red blood cells
- Doing nothing
If it is possible that a patient will need a transfusion (e.g. they are due to have surgery and they are anaemic), they may sometimes be given medications that can reduce the chance of needing a transfusion. For example:
- Tranexamic acid: can be used to reduce blood loss during surgery
- Iron supplementation: can correct anaemia in patients with iron deficiency
What does the transfusion involve?
Briefly explain what having a blood transfusion will involve using patient-friendly language.
Example
“Before the transfusion, a small sample of your blood needs to be obtained to check your blood group. This will be sent to a lab for testing. A small needle called a cannula will be put into a vein in your arm or hand. You will be asked to give your name and date of birth and this will be checked against your ID band and the details on the bag of donor blood selected for you.”
“The blood will flow slowly from the bag via a plastic tube into your vein. It usually takes 2 to 4 hours for each bag of blood to be transfused. Your temperature, blood pressure and pulse will be checked before, during and after the transfusion.”
How the patient might feel during and after the transfusion
A sharp prick may be felt when the cannula is first inserted into the vein, but the patient should not feel anything during the transfusion. Some people develop a fever, chills, or a rash. This is usually treated with paracetamol or by slowing down the transfusion.
The patient’s arm or hand (depending on where the cannula was inserted) may ache and/or have a bruise for a few days after.
Remind the patient that they should contact their GP if they feel unwell, particularly within 24 hours of having a blood transfusion, but any time in the 2 weeks following the transfusion. This is especially important if they have pain in their chest or back, any breathing difficulties, or notice a change in the colour of their skin or urine.
Obtaining consent
Ask if the patient is happy to proceed with the blood transfusion, based on everything you have explained.
Ask if they have any further questions or concerns. If they are unsure, offer to come back later to give them time to think, or to allow them to have a discussion with their family.
Check if the patient has any allergies and ask if they have ever been told they need a special type of blood or have been given an alert card (about antibodies or irradiated blood).
Closing the consultation
Check the patient’s understanding of the information given and ask if they have any questions.
Summarise what you have discussed to emphasise the key points to the patient.
Provide written information on blood transfusion.
Document the discussion in the patient’s notes.
Dispose of PPE and wash your hands.
Patient information leaflets
NHS Blood and Transplant provide a range of UK wide patient information leaflets on blood transfusion and alternatives to transfusion.
Reviewer
Dr Catherine Booth
Consultant in Haematology and Transfusion Medicine
NHS Blood and Transplant and Barts Health NHS Trust
Editor
Dr Chris Jefferies
References
- NICE Guidelines [NG24]. Blood Transfusion. 2015. Available from: [LINK]
- Guidelines from the expert advisory committee on the Safety of Blood, Tissues and Organs (SaBTO) on patient consent for blood transfusion. 2020. Available from: [LINK]
- Serious Hazards of Transfusion (SHOT) – the UK Haemovigilance scheme. Available from: [LINK]
- Joint UKBTS Professional Advisory Committee (JPAC). The estimated residual risk that a donation made in the infectious window period is not detected on testing: risks specific for HBV, HCV and HIV in the UK. 2020. Available from: [LINK]
- Klein AA et al. Association of anaesthetists guidelines: cell salvage for peri-operative blood conservation. 2018. Available from: [LINK]
- NHS Blood and Transplant. Receiving a Blood Transfusion patient information leaflet. Available from: [LINK]
